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Chapter: Paediatrics: Paediatric Surgery

Paediatrics: Perioperative care

All children need to have a history and examination:

Perioperative care

 

Elective children

 

All children need to have a history and examination:

   The presenting complaint should be documented and confirmed.

 

   Previous medical history, medication, and allergies must be recorded.

 

   A brief clinical examination should be performed. In the case of undescended testes, hydroceles, and inguinal hernias a mark should be made on the child’s thigh to document the side for operation (away from the surgical field to prevent tattooing of the wound).

 

   If the child is unwell with an intercurrent illness, discuss with the anaesthetist who may decide that the child is unfit for anaesthesia.

 

Blood tests

 

These should be kept to a minimum. Children undergoing major surgery should have the following done:

   Haemoglobin checked and blood cross-matched, according to the nature of the operation (usually one unit of blood is sufficient).

   Urea and electrolytes should be checked pre-operatively in children taking diuretics, children in renal failure, and children receiving IV fluids.

 

   Children at risk of sickle cell disease or thalassaemia should be screened in outpatients before admission.

 

Fasting prior to elective surgery

 

This is essential for safe induction of anaesthesia. Recommendations from the Association of Paediatric Anaesthetists.

 

Anaesthetist

 

The anaesthetist will visit pre-operatively and discuss anaesthesia and post-operative analgesia with the child and parents. In some instances pre-medication may be appropriate.

 

   IV access will be obtained during induction of anaesthesia and it is sensible to pre-empt this by applying local anaesthetic ointment (e.g. EMLA™) under occlusive dressings to the back of the child’s hands or feet, provided a suitable vein is visible.

   Some anaesthetists are happy for children to come down to theatre wearing their pyjamas; others may request a theatre gown.

   Paediatric anaesthetists generally encourage one parent to accompany the child to the anaesthetic room and many will be happy for the parent to remain with the child during induction.

Newborns

 

Pre-operative resuscitation and preparation are essential if the outcome of surgery is to be successful. Newborns with congenital malformations will be admitted to a neonatal intensive care unit.

 

Routine preparation

 

This should include:

Intramuscular vitamin K.

 

FBC to determine the haemoglobin.

 

Cross-matching blood. Many laboratories require a sample of maternal blood for typing and this should accompany the baby if the mother is unable or unfit to travel.

 

Echocardiography

 

Babies with OA and anorectal malformations should undergo echocar-diography before surgery because of the possible cardiac defects in the VATER association.

 

Renal imaging

 

Provided the baby passes urine (indicative of functioning nephrons) renal imaging can be arranged electively. Anuria necessitates a renal US scan to exclude renal agenesis.

 

Intestinal obstruction

 

Babies will require:

IV fluid: normal maintenance is required. Babies with gastroschisis lose fluid and heat rapidly from the exposed bowel. The baby’s abdomen should be wrapped circumferentially in Clingfilm™ (this does not need to be sterile). Regular bolus infusions of 4.5% albumin solution should be given before closure of the defect.

 

NG decompression: a wide bore NGT is necessary to empty the stomach (8 or 10 French gauge). The NGT should be aspirated every hour and left on free drainage. NG aspirates should be replaced mL for mL with 0.9% saline with 20mmol KCI/L, in addition to maintenance fluids.

 

Biochemistry and acid–base balance: necessary in babies with prolonged vomiting (e.g. pyloric stenosis).

 

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Paediatrics: Paediatric Surgery : Paediatrics: Perioperative care |

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Paediatrics: Paediatric Surgery


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